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With the following treatment options available today, open surgery, where the kidney is opened for stone removal, is usually unnecessary and used in less than one percent of stone cases.

There are several surgery techniques available:

• Extracorporeal Shockwave Lithotripsy (ESWL)
• Percutaneous Nephrolithotomy (PCNL)
• Ureteroscopy

Extracorporeal Shockwave Lithotripsy (ESWL)

A noninvasive process known as lithotripsy (short for extracorporeal shockwave lithotripsy or ESWL) breaks up stones into smaller sand-like fragments that may pass on their own. Shock waves are generated outside the body and focused on the target stone.

This technique has been in the United States since 1984 and is the most frequently used procedure to combat kidney stones. It does not require an incision. The principle for stone destruction among all types of lithotripters is the same. There are different kinds of lithotripters.

Some devices allow the patient to be placed in a water bath to allow the propagation of the shock waves; others use a soft cushion or membrane on which the patient rests for shock wave transmission.

What to expect

1. Prior to the procedure, patients undergo a physical examination, and their history is reviewed.
2. Because this process can produce pain, most patients are given some type of anesthesia.
3. Your doctor will help you decide whether you need only a sedative, regional, or general anesthesia. Most patients receive regional or general anesthesia.
4. Lithotripsy uses x-rays or ultrasound to allow the physician to locate the stone for focusing the lithotripter.
5. The procedure usually lasts 45 minutes to an hour.
6. With the shock waves traveling through body tissue, side effects such as mild skin bruising in the back or abdomen may occur but usually heal in a matter of days. Blood in the urine can be another common side effect. Doctors usually advise patients to avoid taking aspirin, ibuprofen (Advil, Motrin, etc), or other drugs that affect blood clotting prior to treatment to avoid complications.
7. ESWL is usually done on an outpatient basis, and recovery time is usually only one to two days.
8. Patients need to know that ESWL does not remove their stone. When effective, stones are fragmented to be small enough to pass out of the kidney. Because the residual fragments can cause discomfort while they pass, the doctor may insert a stent, a narrow tube placed through the bladder and into the ureter, to assist passage.
9. Repeat ESWL can be a possibility if initial treatment is not successful. Your doctor will evaluate your X-rays to determine if ESWL is appropriate for your stone.

Percutaneous Nephrolithotomy (PCNL)

Percutaneous nephrolithotomy (PCNL) is recommended if the stone is too large or located in a place in the urinary tract that may not allow for effective ESWL results. One advantage PCNL has over ESWL is that the stones are broken and removed in most cases at the time of the surgical procedure.

What to expect

1. Patients have a tube called a nephrostomy tube inserted through a small incision in the flank and into the kidney to help drainage.
2. The surgeon can use the small incision in the back to insert a fiberoptic telescope called a nephroscope. This allows the urologist to view the stone inside the kidney.
3. Smaller stones can be grasped and removed. Larger stones may need to be broken up by an electrohydraulic or ultrasonic energy probe.
4. The patient will need to stay in the hospital for several days with the nephrostomy tube in the back during healing.
5. Once the nephrostomy tube is removed, the incision and kidney will heal in several days, and the patient can return to normal work and exercise usually within one week.

Ureteroscopy

A third type of procedure, called ureteroscopy, allows for treatment of stones in the kidney and the ureter.

What to expect

1. A small telescope, called an ureteroscope (flexible or rigid) is inserted through the urethra (without an incision) into the bladder, ureter and kidney.
2. The stone is then removed via a cage-like instrument (stone basket) or shattered with a holmium laser. A stent is typically left in the ureter to allow for healing.
3. The procedure is done under general anesthesia on an outpatient basis and the stent is removed in the office within 1-2 weeks under cystoscopic guidance using a local anesthetic.
4. The procedure has the benefit of low morbidity, early recovery and precise fragmentation of the stone under direct vision without any harm to surrounding kidney.
5. Unlike ESWL and PCNL, ureteroscopy can be performed in patients on blood thinners. Large stones (>2cm) may be treated as well; however, it may require more than one trip to the operating room.